Combined Intake Form | Accura Denture Clinic

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NEW PATIENT INTAKE FORM

Patient Information
Questions marked with a* are required. Questions you are unsure of or would prefer to answer verbally can be skipped.
Patient name*
First Last
Date of birth
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home phone
Mobile phone
Work phone
Email
How did you hear about us?
- Social Media
- Web search
- Signage
- Television
- Radio
- Community wagon
- Phonebook
- Other
Other
What type of upper dentures do you wear now?*
- None
- Partial Dentures
- Full Dentures
- Implant Dentures
What type of lower dentures do you wear now?*
- None
- Partial Dentures
- Full Dentures
- Implant Dentures
What type of service are you seeking?
- Consultation
- First Dentures
- Replacement Dentures
- Reline Current Dentures
- Repair Current Dentures
Do you have insurance coverage?*
- Yes
- No
Primary Insurer
Carrier
Group/Policy number
ID/Certificate number
Department number
Coverage Amount
A (Basic) % B (Major) % Deductable $
Is the primary policy in your name?*
- Yes
- No
Policy holder name
First Last
Date of birth
Phone number
Relationship
Do you have secondary insurance coverage?*
- Yes
- No
Secondary insurer
Carrier
Group/Policy number
Certificate/ID number
Department number
Coverage Amount
A (Basic) % B (Major) % Deductable $
Is the secondary policy in your name?*
- Yes
- No
Policy holder name
First Last
Date of birth
Phone number
Relationship

NEW PATIENT INTAKE FORM

Consent
Our office understands the importance of your personal information. We will collect and use your personal information in the form of Contact Information; Medical/Dental History; & Financial Information for these appropriate purposes:
- To diagnose and provide safe and efficient health care
- To assess your oral health and advise you of your treatment options
- To communicate with you, a family member, and your other health care providers
- For scheduling appointments, billing purposes, including dental insurance forms
- For teaching and demonstration, on an anonymous basis
- To comply with the College of Denturists, Provincial and Federal regulations and to generally comply with the law
- To comply with the audits and evaluations of the dental practice
- To provide invoices, process credit payments and collect unpaid accounts
- To permit potential purchases or their agents to evaluate and audit the practice in preparation for a potential sale of the practice
Contact information is/may be disclosed to a third party health benefit provider or insurance company when submitting a claim on the patients’ behalf, for payment or reimbursement of all or part of the cost of the treatment provided, or when a patient has requested a preauthorization of a proposed treatment.

By signing this Consent Form you agree that you have provided your personal information. You consent to the collection, use and disclosure of the information for the appropriate purposes listed above. Your information may be accessed by the College of Denturists or other regulatory authorities acting under statute of a legal issue. We will seek your approval, in advance, if a new purpose should arise for the use and/or disclosure. You may withdraw your consent for the use and disclosure of your personal information at any time. We will explain the process and the ramifications of your decision to do so.
Consent*
I authorize release to my benefits plan administrator information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named denturist. This authorization shall continue in effect until the undersigned revokes the same.*
You and your insurance coverage
If you are covered by any kind of private or government dental insurance, there are important things you should know.

First of all, my apologies, (how Canadian!). The outline below comes from thirty years of experience dealing with vague coverage explanations and delayed, denied, or missing insurance payments. Even under the best circumstances, 3–4 hours are spent on the phone with carriers for each claim defending treatment plans, billing fees, or submitting requested resubmissions and treatment records. Your patience is greatly appreciated.

Please read the following carefully:
1. Your insurance contract is between you and your insurance company, not the service provider. We have no influence over their decisions.
2. You will receive a treatment plan from Accura Denture Clinic with total costs before your second appointment. Insurance coverage amounts may not be included if approval is delayed. You are responsible for the total amount minus what your insurance carrier pays.
3. Treatment must be preauthorized by your insurance carrier before services continue. This may take 1–2 weeks.
4. Insurance companies do not always pay the percentages they advertise. Many use formulas, alternate fee schedules, or limited eligible fees that reduce actual payouts. They do not disclose these details to you or to us.
5. Coverage may change when you retire. Some services may be excluded, or your entire plan—including the carrier—may change.
6. Some insurance companies will not communicate with or pay the service provider. If they only pay the member, the entire account balance is due before delivery.
7. Due to the administrative work involved, there are office and claim fees associated with denture services. These “paper fees” can be up to $350.00, depending on what your insurance covers.
8. Some carriers are difficult to negotiate with. It may take months to receive even partial payment. Please be prepared to pay your full account and submit claims yourself. We will assist however we can, including electronic submission with you as the recipient. We will inform you early in treatment if your carrier is known to be problematic.
9. If you have dual coverage (e.g., you and your spouse both have plans), expect delays while the two companies coordinate benefits.
10. As a courtesy, we will attempt to resolve insurance issues on your behalf. However, if no solution is reached within 60 days, the full balance becomes due. You will then need to continue working with your insurance carrier directly. We will provide any necessary paperwork or records.
11. You are responsible for any remaining balance on your account after 60 days, including unpaid insurance amounts.

Patient signature*

Step 1 of 5 - Patient Information

NEW PATIENT INTAKE FORM

Patient Information

Primary Insurer

Secondary insurer

NEW PATIENT INTAKE FORM

Medical history

NEW PATIENT INTAKE FORM

Denture History

Denturist Section

NEW PATIENT INTAKE FORM

Consent

You and your insurance coverage

Please read the following carefully: